As the Earth’s climate grows more inhospitable, so does the civic environment for some of our most vulnerable citizens. From Pittsburgh to Portland, many people experiencing homelessness suffered involuntarily displacement from temporary shelter this summer. At the same time, the demand for shelter, not to mention housing, is higher than ever. Between 2017 and 2022, homelessness increased by 6%.1 To eliminate the visible evidence of homelessness, communities employ strategies such as encampment sweeps, where police or sanitation workers clear out belongings and dwellings. Such involuntary displacement policies are a mistake. They worsen health outcomes and increase mortality instead of addressing the underlying issues leading to homelessness.
As resident physicians, we witness the health impacts of housing insecurity every day. People experiencing homelessness are at higher risk for exacerbations of chronic medical conditions because they cannot store medications, have a higher susceptibility to acute illnesses, such as pneumonia, and are at higher risk for physical violence.2 They are also more vulnerable to climate-related health issues related to air pollution, as well as cold and heat exposure. Indeed, heat kills more people worldwide than any other climate-related event.3
Involuntary displacement policies harm people experiencing homelessness. During a sweep, they may lose critical belongings, such as IDs, medications, sterile injection supplies, and naloxone.4 Displacement often disconnects this population from local support services, like street medicine teams,2 and from their own communities, which detrimentally affects mental health. More than 30% of people experiencing homelessness have a substance use disorder and are at higher risk for infections from drug use and death from drug overdose—over a 10-year period, it is estimated that involuntary displacement leads to a 25% increase in all-cause mortality for individuals experiencing homelessness that also inject drugs.4 If these glaring health threats were not enough, these policies are also costly to local governments, diverting funds from initiatives which could address root causes of homelessness such as high cost of living, and underfunded social safety net supports.4,5
Proponents of involuntary sweeps argue that temporary encampments are unsafe, detrimental for public health, and disruptive to communities. We reject the implication that the lives of the people displaced matter less than the comfort of their housed neighbors. Others who support dissolution of encampments may extol the virtues of “Housing First” policies which seek to provide housing to persons experiencing homelessness as the first and most important step to improving health. Unfortunately, rapid access to housing is not always feasible due to high housing prices and limitations of municipal social safety net supports.4,5 A temporary shelter or an encampment can provide important risk mitigation for unhoused people by offering safety, protection from the elements, and community. The simple fact of having a community can be lifesaving in the event of overdose, assault, or illness.
We call upon our physician colleagues to advocate for people experiencing homelessness by standing against involuntary displacement policies and supporting evidence-based strategies to combat homelessness in our communities. On a civic level, we can use our expertise to oppose encampment sweeping and support legislation that increases funding for housing navigation and other social services. This can be accomplished by writing a letter to local government officials, participating in town halls or council meetings, and mobilizing the power of local physician organizations to work with local politicians to create such legislation. We can also make a stronger effort to vote in local and state elections and help register our colleagues and patients to do the same. Finally, we can leverage the power of our social media networks by raising awareness about this issue while engaging with local politicians and amplifying the voices of local activists and people experiencing homelessness.
On a clinical level, we can use harm-reduction measures to mitigate risks of comorbidities associated with homelessness. When seeing patients in any setting, implement a universal screen for housing instability into your practice. If identified, it will be important to assess for the unique health burdens that come with homelessness or housing instability, including access to safe storage for medications, availability of air-conditioning or heating (and awareness of local cooling centers), and presence of a substance use disorder. Information on local resources can also be helpful to distribute to patients, share with other providers, and use on the clinics/wards. This includes local street medicine or mobile healthcare groups, safe syringe initiatives, and programs to screen and treat communicable diseases. Physicians should also be aware of available respite care facilities modeled after the Barbara McInnis House in Boston, which provides recovery medical care for people experiencing homelessness after acute medical illnesses, surgeries, or chemotherapy. If these lifesaving resources are not present, then we should support establishing these services with local academic or community health centers.
Housing is a human right and governments incapable of housing everyone must at least allow for basic shelter. Shelter, no matter how imperfect, can be the difference between life or death for people experiencing homelessness.
- State of homelessness: 2023 edition. National Alliance to End Homelessness. https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness/. Accessed October 15, 2023.
- Chang JS, Riley PB, Aguirre RJ, et al. Harms of encampment abatements on the health of unhoused people. SSM Qual Res in Health. 2022; 2:100064. https://doi.org/10.1016/j.ssmqr.2022.100064.
- Adams-Fuller T. Extreme heat is deadlier than hurricanes, floods and tornadoes combined. Scientific American. https://www.scientificamerican.com/article/extreme-heat-is-deadlier-than-hurricanes-floods-and-tornadoes-combined/. Published July 1, 2023. Accessed October 15, 2023.
- Barocas JA, Nall SK, Axelrath S, et al. Population-level health effects of involuntary displacement of people experiencing unsheltered homelessness who inject drugs in US cities. JAMA. 2023;329(17):1478-1486. https://doi.org/10.1001/jama.2023.4800.
- Perez R. Homeless encampment sweeps may be draining your city’s budget. Housing Matters. https://housingmatters.urban.org/feature/homeless-encampment-sweeps-may-be-draining-your-citys-budget. Published January 4, 2023. Accessed August 9, 2023.
Advocacy, Clinical Practice, Health Policy & Advocacy, SGIM, Social Determinants of Health
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